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E/M Auditing- HELP

anne32

Networker
Messages
95
Best answers
0
So I am auditing our providers charts for E/M levels. We are supposed to "show our work" and break down the documentation to show how many HPI elements we find, ROS, PFSH and then show what the total history is. Then the Exam and MDM. Then show what the total E/M level equals out to. My problem with this is that sometimes the documentation calculates to lets say a 99214 for someone that came in for a cold, and I would really code it as a 99213. How do you explain this to providers? All of the documentation equals a certain level, but that scrap that I would actually code this completely different? What do you do in this situation? I mentioned this to my manager and she said most of our providers down code anyway and this is just good feedback for them. Any help is appreciated!
 

npricercm

Guest
Messages
282
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So I am auditing our providers charts for E/M levels. We are supposed to "show our work" and break down the documentation to show how many HPI elements we find, ROS, PFSH and then show what the total history is. Then the Exam and MDM. Then show what the total E/M level equals out to. My problem with this is that sometimes the documentation calculates to lets say a 99214 for someone that came in for a cold, and I would really code it as a 99213. How do you explain this to providers? All of the documentation equals a certain level, but that scrap that I would actually code this completely different? What do you do in this situation? I mentioned this to my manager and she said most of our providers down code anyway and this is just good feedback for them. Any help is appreciated!
It would depend on what your particular facility considers their standard. Currently it is the test is the highest of 2 of the 3 elements. Follow the guidelines your manager has set. The cold example may not be the whole story, the provider may know something that we don't. We don't determine medical necessity we are not clinicians. I have had cases where I think the code should be lower based on MDM, but cannot change it; we only educate the doctor about MDM because we are not clinician.

Your manager is correct in stating that providers do downcode accordingly. If you didn't agree and thought that the elements warranted a higher code would you change the code to a higher level?
 

Najwa

Networker
Local Chapter Officer
Messages
84
Location
Gainesville (NCF) Florida
Best answers
0
E&M

A cold seems to be minor for sure. It is easy to document a level 4 for any problem. However, the question to ask - Is it really medically necessary. If the patient has only this one problem, then I too would question a level 4. However, a patient with multiple other chronic conditions that add to complexity of decision-making, it may increased the risk to patient mortality and may lead to a level 4. I find discussion with the providers is key to helping them understand the difference between the levels of service.

Just my 2 cents.
 

jimbo1231

Expert
Messages
374
Location
Brooklyn, New York
Best answers
0
Documentation Creep

I agree with Najwa. Actually auditors do have to question medical necessity sometimes. If we don't every 4 and 5 will go through based on the ease of documenting Detailed and Comprehensive H&Ps with EMRs. This doesn't mean that there might be something else going on in the example cited of the patient with a cold. But it's not good enough that the provider was thinking something else or that the facility has guideline. Documentation should be in the chart for that visit. Jim
 
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